Patient Is Discharged From Hospital and Admitted to Nursing Facility on Same Day

D. Hospital Discharge Management (CPT Codes 99238 and 99239) and Nursing Facility Admission Code When Patient Is Discharged From Hospital and Admitted to Nursing Facility on Same Day 

Contractors pay the hospital discharge code (codes 99238 or 99239) in addition to a nursing facility admission code when they are billed by the same physician with the same date of service.


If a surgeon is admitting the patient to the nursing facility due to a condition that is not as a result of the surgery during the postoperative period of a service with the global surgical period, he/she bills for the nursing facility admission and care with a modifier “-24” and provides documentation that the service is unrelated to the surgery (e.g., return of an elderly patient to the nursing facility in which he/she has resided for five years following discharge from the hospital for cholecystectomy).

Contractors do not pay for a nursing facility admission by a surgeon in the postoperative period of a procedure with a global surgical period if the patient’s admission to the nursing facility is to receive post operative care related to the surgery (e.g., admission to a nursing facility to receive physical therapy following a hip replacement). Payment for the nursing facility admission and subsequent nursing facility services are included in the global fee and cannot be paid separately.



E. Hospital Discharge Management and Death Pronouncement

Only the physician who personally performs the pronouncement of death shall bill for the face-to-face Hospital Discharge Day Management Service, CPT code 99238 or 99239.

The date of the pronouncement shall reflect the calendar date of service on the day it was performed even if the paperwork is delayed to a subsequent date

Hospital Observation Services During Global Surgical Period - Billing Guide

The global surgical fee includes payment for hospital observation (codes 99217, 99218, 99219, 99220, 99224, 99225, 99226, 99234, 99235, and 99236) services unless the criteria for use of CPT modifiers “-24,” “-25,” or “-57” are met. Contractors must pay for these services in addition to the global surgical fee only if both of the following requirements are met:

• The hospital observation service meets the criteria needed to justify billing it with CPT modifiers “-24,” “-25,” or “-57” (decision for major surgery); and

• The hospital observation service furnished by the surgeon meets all of the criteria for the hospital observation code billed.

Examples of the decision for surgery during a hospital observation period are:

• An emergency department physician orders hospital outpatient observation services for a patient with a head injury. A neurosurgeon is called in to evaluate the need for surgery while the patient is receiving observation services and decides that the patient requires surgery. The surgeon would bill a new or established office or other outpatient visit code as appropriate with the “-57” modifier to indicate that the decision for surgery was made during the evaluation. The surgeon must bill the office or other outpatient visit code because the patient receiving hospital outpatient observation services is not an inpatient of the hospital. Only the physician who ordered hospital outpatient observation services may bill for observation care.

• A neurosurgeon orders hospital outpatient observation services for a patient with a head injury. During the observation period, the surgeon makes the decision for surgery. The surgeon would bill the appropriate level of hospital observation code with the “-57” modifier to indicate that the decision for surgery was made while the surgeon was providing hospital observation care.


Examples of hospital observation services during the postoperative period of a surgery are:

• A surgeon orders hospital outpatient observation services for a patient with abdominal pain from a kidney stone on the 80th day following a TURP (performed by that surgeon). The surgeon decides that the patient does not require surgery. The surgeon would bill the observation code with CPT modifier “-24” and documentation to support that the observation services are unrelated to the surgery.

• A surgeon orders hospital outpatient observation services for a patient with abdominal pain on the 80th day following a TURP (performed by that surgeon). While the patient is receiving hospital outpatient observation services, the surgeon decides that the patient requires kidney surgery. The surgeon would bill the observation code with HCPCS modifier “-57” to indicate that the decision for surgery was made while the patient was receiving hospital outpatient observation services. The subsequent surgical procedure would be reported with modifier “-79.”

• A surgeon orders hospital outpatient observation services for a patient with abdominal pain on the 20th day following a resection of the colon (performed by that surgeon).
The surgeon determines that the patient requires no further colon surgery and discharges the patient. The surgeon may not bill for the observation services furnished during the global period because they were related to the previous surgery.

An example of a billable hospital observation service on the same day as a procedure is when a physician repairs a laceration of the scalp in the emergency department for a patient with a head injury and then subsequently orders hospital outpatient observation services for that patient. The physician would bill the observation code with a CPT modifier 25 and the procedure code.

Drug Administration Services and E/M Visits Billed on Same Day of Service

MACs must advise physicians that CPT code 99211 cannot be paid if it is billed with a drug administration service such as a chemotherapy or nonchemotherapy drug infusion code (effective January 1, 2004). This drug administration policy was expanded in the Physician Fee Schedule Final Rule, November 15, 2004, to also include a therapeutic or diagnostic injection code (effective January 1, 2005). Therefore, when a medically necessary, significant and separately identifiable E/M service (which meets a higher complexity level than CPT code 99211) is performed, in addition to one of these drug administration services, the appropriate E/M CPT code should be reported with modifier -25. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required.

C. Office/Outpatient or Emergency Department E/M Visit on Day of Admission to Nursing Facility

MACs may not pay a physician for an emergency department visit or an office visit and a comprehensive nursing facility assessment on the same day. Bundle E/M visits on the same date provided in sites other than the nursing facility into the initial nursing facility care code when performed on the same date as the nursing facility admission by the same physician.

Reporting a Medically Necessary E/M Service Furnished During the Same Encounter as an IPPE or AWV

When the physician or qualified NPP, or for AWV the health professional, provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or an AWV, CPT codes 99201 – 99215 may be reported depending on the clinical appropriateness of the circumstances. CPT Modifier –25 shall be appended to the medically necessary E/M service identifying this service as a significant, separately identifiable service from the IPPE or AWV code reported (HCPCS code G0344 or G0402, whichever applies based on the date the IPPE is performed, or HCPCS code G0438 or G0439 whichever AWV code applies).

NOTE: Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the IPPE or AWV and should not be included when determining the most appropriate level of E/M service to be billed for the medically necessary, separately identifiable, E/M service.


Billing for Medically Necessary Visit on Same Occasion as Preventive Medicine Service



When a physician furnishes a Medicare beneficiary a covered visit at the same place and on the same occasion as a noncovered preventive medicine service (CPT codes 99381-99397), consider the covered visit to be provided in lieu of a part of the preventive medicine service of equal value to the visit. A preventive medicine service (CPT codes 99381-99397) is a noncovered service. The physician may charge the beneficiary, as a charge for the noncovered remainder of the service, the amount by which the physician’s current established charge for the preventive medicine service exceeds his/her current established charge for the covered visit. Pay for the covered visit based on the lesser of the fee schedule amount or the physician’s actual charge for the visit. The physician is not required to give the beneficiary written advance notice of noncoverage of the part of the visit that constitutes a routine preventive visit. However, the physician is responsible for notifying the patient in advance of his/her liability for the charges for services that are not medically necessary to treat the illness or injury.

There could be covered and noncovered procedures performed during this encounter (e.g., screening x-ray, EKG, lab tests.). These are considered individually. Those
procedures which are for screening for asymptomatic conditions are considered noncovered and, therefore, no payment is made. Those procedures ordered to diagnose or monitor a symptom, medical condition, or treatment are evaluated for medical necessity and, if covered, are paid.

Emergency patient - service provided by two physician

E. Physician Billing for Emergency Department Services Provided to Patient by Both Patient’s Personal Physician and Emergency Department Physician

If a physician advises his/her own patient to go to an emergency department (ED) of a hospital for care and the physician subsequently is asked by the ED physician to come to the hospital to evaluate the patient and to advise the ED physician as to whether the patient should be admitted to the hospital or be sent home, the physicians should bill as follows:

• If the patient is admitted to the hospital by the patient’s personal physician, then the patient’s regular physician should bill only the appropriate level of the initial hospital care (codes 99221 - 99223) because all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. The ED physician who saw the patient in the emergency department should bill the appropriate level of the ED codes.

• If the ED physician, based on the advice of the patient’s personal physician who came to the emergency department to see the patient, sends the patient home, then the ED physician should bill the appropriate level of emergency department service. The patient’s personal physician should also bill the level of emergency department code that describes the service he or she provided in the emergency department. If the patient’s personal physician does not come to the hospital to see the patient, but only advises the emergency department physician by telephone, then the patient’s personal physician may not bill.



F. Emergency Department Physician Requests Another Physician to See the Patient in Emergency Department or Office/Outpatient Setting

If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code. If the patient is admitted to the hospital by the second physician performing the evaluation, he or she should bill an initial hospital care code and not an emergency department visit code.

Emergency Department Visits (Codes 99281 - 99288)

A. Use of Emergency Department Codes by Physicians Not Assigned to Emergency Department

Any physician seeing a patient registered in the emergency department may use emergency department visit codes (for services matching the code description). It is not required that the physician be assigned to the emergency department.



B. Use of Emergency Department Codes In Office

Emergency department coding is not appropriate if the site of service is an office or outpatient setting or any sight of service other than an emergency department. The emergency department codes should only be used if the patient is seen in the emergency department and the services described by the HCPCS code definition are provided. The emergency department is defined as an organized hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention.



C. Use of Emergency Department Codes to Bill Nonemergency Services

Services in the emergency department may not be emergencies. However the codes (99281 - 99288) are payable if the described services are provided.

However, if the physician asks the patient to meet him or her in the emergency department as an alternative to the physician’s office and the patient is not registered as a patient in the emergency department, the physician should bill the appropriate office/outpatient visit codes. Normally a lower level emergency department code would be reported for a nonemergency condition.



D. Emergency Department or Office/Outpatient Visits on Same Day As Nursing Facility Admission

Emergency department visit provided on the same day as a comprehensive nursing facility assessment are not paid. Payment for evaluation and management services on the same date provided in sites other than the nursing facility are included in the payment for initial nursing facility care when performed on the same date as the nursing facility admission.

Patient seen on hospital and office clinic same day - Billing guide

SPLIT/SHARED E/M SERVICE

Office/Clinic Setting

In the office/clinic setting when the physician performs the E/M service the service must be reported using the physician’s UPIN/PIN. When an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed “incident to” if the requirements for “incident to” are met and the patient is an established patient. If “incident to” requirements are not met for the shared/split E/M service, the service must be billed under the NPP’s UPIN/PIN, and payment will be made at the appropriate physician fee schedule payment.

Hospital Inpatient/Outpatient (On Campus or Off Campus)/Emergency Department Setting

When a hospital inpatient/hospital outpatient (on campus-outpatient hospital or off campus outpatient hospital) or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's UPIN/PIN number. However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the NPP's UPIN/PIN. Payment will be made at the appropriate physician fee schedule rate based on the UPIN/PIN entered on the claim.



EXAMPLES OF SHARED VISITS

1. If the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service.

2. In an office setting the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the "incident to" requirements are met, the physician reports the service. If the “incident to” requirements are not met, the service must be reported using the NPP’s UPIN/PIN.

In the rare circumstance when a physician (or NPP) provides a service that does not reflect a CPT code description, the service must be reported as an unlisted service with CPT code 99499. A description of the service provided must accompany the claim. The MAC has the discretion to value the service when the service does not meet the full terms of a CPT code description (e.g., only a history is performed). The MAC also determines the payment based on the applicable percentage of the physician fee schedule depending

on whether the claim is paid at the physician rate or the non-physician practitioner rate. CPT modifier -52 (reduced services) must not be used with an evaluation and management service. Medicare does not recognize modifier -52 for this purpose.

Initial Hospital Care Service History and Physical That Is Less Than Comprehensive CPT 99499

When a physician performs a visit that meets the definition of a Level 5 office visit several days prior to an admission and on the day of admission performs less than a comprehensive history and physical, he or she should report the office visit that reflects the services furnished and also report the lowest level initial hospital care code (i.e., code 99221) for the initial hospital admission. Contractors pay the office visit as billed and the Level 1 initial hospital care code.

Physicians who provide an initial visit to a patient during inpatient hospital care that meets the minimum key component work and/or medical necessity requirements shall report an initial hospital care code (99221-99223). The principal physician of record shall append modifier “-AI” (Principal Physician of Record) to the claim for the initial hospital care code. This modifier will identify the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care.

Physicians may bill initial hospital care service codes (99221-99223), for services that were reported with CPT consultation codes (99241 – 99255) prior to January 1, 2010, when the furnished service and documentation meet the minimum key component work and/or medical necessity requirements. Physicians must meet all the requirements of the initial hospital care codes, including “a detailed or comprehensive history” and “a detailed or comprehensive examination” to report CPT code 99221, which are greater than the requirements for consultation codes 99251 and 99252.

Subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history.” An E/M service that could be described by CPT consultation code 99251 or 99252 could potentially meet the component work and medical necessity requirements to report 99231 or 99232. Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241 – 99255) prior to January 1, 2010,where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.


Reporting CPT code 99499 (Unlisted evaluation and management service) should be limited to cases where there is no other specific E/M code payable by Medicare that describes that service. Reporting CPT code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. Contractors shall expect reporting under these circumstances to be unusual.

Observation CPT code 99224, 99226 , 99234 , 99236 - Q & A

Are observation codes considered outpatient or inpatient?

Q. Are observation care codes 99224-99226 and 99234-99236 considered outpatient or inpatient codes?
A. The Centers for Medicare and Medicaid Services (CMS) Internet-only manual directly addresses this point by explaining that while a patient is in observation care they are not considered an inpatient of the hospital. These codes (99224-99226 and 99234-99236) are designated as hospital outpatient observation services.

Q. Does the billing physician need to document the time the patient spent in observation care, or the time the physician spent tending to the patient?
A. The time that must be documented relates to the time that the patient is in observation care. Note that the codes selected regarding services furnished during this time are directly related to how long the patient remains in this status.codes (99224-99226 and 99234-99236) are designated as hospital outpatient observation services.


Q. Does the documentation of the time and date that a patient is in observation care pertain to the time during which the patient was admitted to observation care, or does it start at the time that the physician provides services (i.e., completes a history and physical)?

A. Per the Centers for Medicare & Medicaid Services (CMS) Internet-only manual (IOM):
Observation time begins at the clock time documented in the patient’s medical record, which coincides with the time that observation care is initiated in accordance with a physician’s order.
Observation time ends when all medically necessary services related to observation care are completed.

Specific coding guidelines are given in the IOM, based on the total time during which the patient is admitted for observation care, without regard to when specific services are provided.


Where to find detailed scenarios pertaining to observation care codes
Q. Where can I find information explaining and distinguishing between codes and guidelines pertaining to observation care and/or inpatient admission/discharge?

A. The CMS Internet-only manual provides detailed scenarios pertaining to observation care coding, and guidelines regarding billing/coding for inpatient hospital services.



Physician must document date and time of medical record

Q. In regard to observation care, must a physician document date and time in the medical record, or is the nursing documentation sufficient to verify date and time?

A. Regarding documentation requirements on behalf of a physician who is billing for observation care, the Internet-only manual states:
For a physician to bill the initial observation care codes, there must be a medical observation record for the patient which contains dated and timed physician’s orders regarding the observation services the patient is to receive, nursing notes, and progress notes prepared by the physician while the patient received observation services. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter


Observation care vs. time spent tending to the patient

Q. Does the billing physician need to document the time the patient spent in observation care, or the time the physician spent tending to the patient?
A. The time that must be documented relates to the time that the patient is in observation care. Note that the codes selected regarding services furnished during this time are directly related to how long the patient remains in this status.

Patient seen in Emergency department after admitted in Hospital? and Medicare downcoded the CPT ?

Q. If a patient is seen in the emergency department, then admitted to the hospital, how should this be billed?
A. As stated in the CMS Internet-only Manual:
Contractors pay for an initial hospital care service if a physician sees a patient in the emergency room and decides to admit the person to the hospital. They do not pay for both E/M services. Also, they do not pay for an emergency department visit by the same physician on the same date of service. When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.

CPT® code 99058 not recognized as a billable service by Medicare program

Q. We treated a patient in the office on an emergency basis. CPT® codes 99212-25 (Office or other outpatient visit, with modifier 25 to indicate a significant, separately identifiable E/M visit on the same date as another procedure), 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service) and 51705 (Change of cystostomy tube; simple) were billed. Can we be reimbursed for the office ER code 99058?

A. Current Procedural Terminology® (CPT®) code 99058 is not a recognized service billable to the Medicare program. The services are billed according to the actual level of care provided to the patient. There is no additional reimbursement for disruption of other scheduled office services.


Q. We submitted a claim with HCPCS code 99233 (Subsequent hospital care) to Medicare and it was downcoded to 99232. Upon inquiring why this change was made, we were told levels were compared to levels of other doctors who were seeing the patient on the same day. Is this correct?

A. No, this is not correct.
In order for the Medical Review department to downcode an E/M service, the documentation is reviewed. In this case, the nurse reviewer must have been unable to identify all elements required for the level of care being billed. In all cases, you should review the records you submit to verify if the correct level of care was selected based on the 1995 or 1997 E/M guidelines. If you disagree with the findings, you may request an appeal, wherein a new reviewer will look at the documentation provided.

Reviewing of Medical record and decision Making Q & A

Q. Can I refer to someone else’s dictated note and get credit for those parts of the history I reviewed?
A. Yes - review of “old records” is part of the medical decision-making process.


Q. If I review my own previous notes and summarize my findings, would I get credit for “review and summation of old records”?
A. No, credit would not be given for summarizing one’s own previous records.


Q. If I document allergies, do I get credit for an element of past medical history, or is this counted as part of the review of systems (Allergic/Immunologic) (or both)?
A. The single element of allergies would only be counted once (for either past medical history or review of systems).



Q. Can I use elements of History of Present Illness (HPI) as elements of Review of Systems (ROS) and have them both count, or is it one or the other? For example if the patient has chest pain which is “associated with shortness of breath” in the HPI, does this also count as an element of respiratory ROS?
A. The same element would only be counted once. In the example given, there are two different elements indicated (shortness of breath and chest pain), so this would count for both HPI and ROS, respectively.


Q. Do you use the numeric conversion for the 1995 E/M guidelines (i.e., problem focused exam: one system and/or body area, expanded problem focused exam: 2-4 organ systems and/or body areas, detailed exam: 5-7 body areas and/or organ systems, comprehensive: 8 organ systems)?
A. The 1995 guidelines do not specify exact numbers -- problem focused implies one system/area, and only comprehensive has a numeric indication (8).





Q. What is the definition of “self-limited” or “minor” problem vs. “new stable problem?”
A. A new, stable problem is a new problem, which is not worsening. A self-limited or minor problem is of less severity and would be expected to run its course uneventfully.


Q. When referring to my own previously dictated notes for the Review of Systems (ROS) and Past, Family and Social History (PFSH), do I have to note the date AND location of the previous note, e.g., “Previous PFSH and complete ROS was reviewed with the patient and is unchanged. For details, please refer to my dictated note IN THIS CHART dated 5/6/09.”
A. Yes -- when referring to previous notes, specific information must be given regarding when and where.


Q. When calculating the medical decision-making, are problems defined as “old” or “new” relative to the patient or to the physician?
A. Regarding the medical decision-making component, the designations of “old” and “new” are relative to the physician.

Prescription Drug Management in Medical record

Q. During an evaluation and management visit, what constitutes “prescription drug management?”

A. “Prescription drug management” is based on documented evidence that the provider has evaluated medications as part of a service, in relation to the patient. This may be a prescription being written or discontinued, or a decision to maintain a current medication/dosage.
Note: Simply listing current medications is not considered “prescription drug management.”


Q. What is required to get credit for prescription drug management? Do I have to stop, start or change a medication dosage, or can I get credit for making the decision to continue a specific medication?
A. Credit is given as long as the documentation clearly indicates that decision-making took place in regard to the medication(s).

Q. Is prescription drug management enough to establish a moderate level of risk for medical decision-making?
A. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category determines the overall risk.


Q. Is prescription drug management enough to establish a moderate level of risk for medical decision-making?
A. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category determines the overall risk.



Q. In medical-decision making, how does one determine further work-up under “number of diagnoses”?
A. A key element of the medical-decision making category includes management decisions made by the physician to determine a diagnosis and treatment. Evidence of further work-up within documentation would include: indicating a problem is worsening/probable and/or listing possible management options, advice sought, referrals or consultations, and the initiation of or change in treatment.


Q. What does a “self-limited or minor problem” mean? Can you please give some examples?
A. A self-limited or minor problem is one in which the resolution is expected to be fairly rapid, with minimal medical intervention.  Examples would be a cold or an insect bite.

E & M Visit Q & A - Do physician required to document the date in Medical record - Observation care ?

Q. In regard to observation care, must a physician document date and time in the medical record, or is the nursing documentation sufficient to verify date and time?

A. Regarding documentation requirements on behalf of a physician who is billing for observation care, the Internet-only manual states:

For a physician to bill the initial observation care codes, there must be a medical observation record for the patient which contains dated and timed physician’s orders regarding the observation services the patient is to receive, nursing notes, and progress notes prepared by the physician while the patient received observation services. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter.



Q. If my office uses an E/M questionnaire for the Past, Family and Social History (PFSH) and Review of Systems (ROS), is it mandatory that the physician sign and date the form?

A. It is mandatory that the physician’s documentation clearly indicates that the forms have been reviewed by him/her, and that any follow-up on positive and pertinent negative responses is documented.


Q. Can I document the most clinically relevant systems and then say “all other systems reviewed are negative” in order to qualify for a complete (10 system) ROS?
A. This would be allowed if all other systems were, indeed, reviewed and are negative, and if a complete ROS is medically necessary.


Q. If the patient’s medical record indicates that the PFSH is “non-contributing” with regard to the patient’s condition, does this documentation support that the PFSH was reviewed?

A. If the record indicates that the patient’s past, family, and social history (PFSH) is “non-contributing,” it may be inferred that the practitioner did not ask the patient about his or her PFSH. However, if the practitioner has reviewed the patient’s PFSH, it should be documented in the medical record.

Q. When referring to my own previously dictated notes for the Review of Systems (ROS) and Past, Family and Social History (PFSH), do I have to note the date AND location of the previous note, e.g., “Previous PFSH and complete ROS was reviewed with the patient and is unchanged. For details, please refer to my dictated note IN THIS CHART dated 5/6/09.”

A. Yes -- when referring to previous notes, specific information must be given regarding when and where.